Open-label, Phase 2 study of roxadustat for the treatment of anemia in patients receiving chemotherapy for non-myeloid malignancies.

Anemia is a common side effect of myelosuppressive chemotherapy; however, chemotherapy-induced anemia (CIA) management options are suboptimal. We evaluated the efficacy and safety of roxadustat in this setting. This open-label Phase 2 study included patients with non-myeloid malignancies and CIA (hemoglobin [Hb] ≤10 g/dL) who had planned concurrent myelosuppressive chemotherapy for ≥8 additional weeks. Oral roxadustat was administered for ≤16 weeks (starting dose 2.0 or 2.5 mg/kg, then titrated every 4 weeks). The primary efficacy endpoint was mean maximum change in Hb within 16 weeks of baseline without red blood cell (RBC) transfusion. Patients were assigned to roxadustat 2.0 (n = 31) or 2.5 mg/kg (n = 61) starting doses, and 89 were assessed for efficacy. The mean (standard deviation) maximum Hb change from baseline without RBC transfusion was 2.4 (1.5) and 2.5 (1.5) g/dL in the roxadustat 2.0 and 2.5 mg/kg groups, respectively. Median (range) time to Hb increase of ≥2 g/dL was 71 (57-92) days. Twelve patients (14.5%) had RBC transfusions (Week 5 to the end of treatment). Roxadustat was efficacious regardless of tumor type and chemotherapy regimen. Deep vein thrombosis (DVT) and pulmonary embolism (PE) occurred in 14 (15.2%) and nine (9.8%) patients, respectively, and three had serious adverse events attributed to roxadustat in the opinion of the investigators (PE: n = 2 [2.2%]; DVT: n = 1 [1.1%]). Roxadustat increased Hb in patients with CIA regardless of tumor type and chemotherapy regimen. Adverse events were consistent with observations in patients with advanced-stage malignancies.

Correction of iron deficiency in hospitalized heart failure patients does not improve patient outcomes.

Heart failure (HF) has an estimated prevalence of 1-2% in the world's population and up to 10% of patients age 65 and above. Iron deficiency (ID) in HF has been shown to be an independent contributor of increased mortality and poorer quality of life and has been associated with increased rates of hospitalization. Estimates are varied, but it is believed that as many as 30-83% of HF patients have ID, often without overt anemia, therefore making diagnosis more difficult. Well-established large studies have shown intravenous iron (IVFe) supplementation in HF patients is superior to an oral route, though these guidelines were developed for the chronic HF patients in the outpatient setting. For patients who are frequently hospitalized for HF, their inpatient stays may present an opportunity to diagnose ID. We previously showed that ID is underdiagnosed in the inpatient setting. To date, limited studies investigate long-term outcomes in hospitalized HF patients diagnosed with ID who are treated with IVFe compared to those who are not. In this retrospective analysis, we assessed 1-year readmission rates and mortality outcomes in patients who were diagnosed with ID while admitted for HF and subsequently received IVFe versus those who did not on their initial admission. These data suggest that there is no significant reduction in readmissions for HF or mortality between those patients who received IVFe and those who did not.

A Review of Growth Factor Support in Bloodless Autologous Hematopoietic Stem Cell Transplant.

Bloodless autologous hematopoietic cell transplantation is associated with risks of severe bleeding and profound anemia. RBC or platelet transfusions are often used to prevent these hematologic complications. However, in patients such as Jehovah's Witnesses who refuse major blood components, the lack of transfusion support is not an absolute contraindication to an autologous hematopoietic cell transplant. Pennsylvania Hospital performed the world's first bloodless hematopoietic cell transplant more than 15 years ago and has gradually improved its technique with a sizable patient population. Erythropoiesis-stimulating agents were successfully employed as part of their pretransplant regimen to prevent severe anemia. Thrombopoietin agonists' potential role in bloodless transplant is also currently being explored. Although there is limited literature, available reports in combination with physiologic reasoning may support the use of these growth factors to promote transplant success. These agents offer potential benefit and may be of utility in minimizing complications of a bloodless transplant. In this review, we summarize the available literature and offer insight into how we may incorporate growth factors to allow bloodless autologous hematopoietic cell transplantation to be an available option to patients who may otherwise be denied.

Iron deficiency in heart failure, an underdiagnosed and undertreated condition during hospitalization.

Heart failure (HF) is a chronic medical condition affecting an estimated 1-2% of the world's population, and as many as 10% of patients age 65 and above. Among patients with HF, iron deficiency (ID) has an estimated prevalence of 30-83%, often without concomitant anemia. Thus, ID in HF is often underdiagnosed unless actively sought after. ID in HF has been shown to be an independent contributor of increased mortality, hospitalization, and early readmission compared with HF patients without ID or HF patients with anemia without ID. Previous trials suggest that intravenous iron supplementation for patients with chronic HF and ID with or without anemia has resulted in improved functional outcomes and quality of life; however, the role of iron supplementation in patients hospitalized with HF has not been well characterized. In this retrospective analysis conducted in a large urban health system, we show that of the greater than 10,000 patients admitted for HF in 1 year, only 158 patients underwent screening for ID. Of these, 109 met criteria for ID. Despite intravenous iron being the standard of care for treatment of ID in HF patients, only 23 patients received this therapy. These data suggest that iron deficiency, despite having major implications in HF, is not being adequately evaluated during hospitalizations for HF. Further, if ID is identified, it is not being appropriately addressed, as per current treatment guidelines.

Get screened: a randomized trial of the incremental benefits of reminders, recall, and outreach on cancer screening.

BACKGROUND: Rates of breast cancer (BC) and colorectal cancer (CRC) screening are particularly low among poor and minority patients. Multifaceted interventions have been shown to improve cancer-screening rates, yet the relative impact of the specific components of these interventions has not been assessed. Identifying the specific components necessary to improve cancer-screening rates is critical to tailor interventions in resource limited environments. OBJECTIVE: To assess the relative impact of various components of the reminder, recall, and outreach (RRO) model on BC and CRC screening rates within a safety net practice. DESIGN: Pragmatic randomized trial. PARTICIPANTS: Men and women aged 50-74 years past due for CRC screen and women aged 40-74 years past due for BC screening. INTERVENTIONS: We randomized 1,008 patients to one of four groups: (1) reminder letter; (2) letter and automated telephone message (Letter + Autodial); (3) letter, automated telephone message, and point of service prompt (Letter + Autodial + Prompt); or (4) letter and personal telephone call (Letter + Personal Call). MAIN MEASURES: Documentation of mammography or colorectal cancer screening at 52 weeks following randomization. KEY RESULTS: Compared to a reminder letter alone, Letter + Personal Call was more effective at improving screening rates for BC (17.8 % vs. 27.5 %; AOR 2.2, 95 % CI 1.2-4.0) and CRC screening (12.2 % vs. 21.5 %; AOR 2.0, 95 % CI 1.1-3.9). Compared to letter alone, a Letter + Autodial + Prompt was also more effective at improving rates of BC screening (17.8 % vs. 28.2 %; AOR 2.1, 95 % CI 1.1-3.7) and CRC screening (12.2 % vs. 19.6 %; AOR 1.9, 95 % CI 1.0-3.7). Letter + Autodial was not more effective than a letter alone at improving screening rates. CONCLUSIONS: The addition of a personal telephone call or a patient-specific provider prompt were both more effective at improving mammogram and CRC screening rates compared to a reminder letter alone. The use of automated telephone calls, however, did not provide any incremental benefit to a reminder letter alone.

Randomized, controlled trial of a multimodal intervention to improve cancer screening rates in a safety-net primary care practice.

BACKGROUND: Cancer screening rates are suboptimal for low-income patients. OBJECTIVE: To assess an intervention to increase cancer screening among patients in a safety-net primary care practice. DESIGN: Patients at an inner-city family practice who were overdue for cancer screening were randomized to intervention or usual care. Screening rates at 1 year were compared using the chi-square test, and multivariable analysis was performed to adjust for patient factors. SUBJECTS: All average-risk patients at an inner-city family practice overdue for mammography or colorectal cancer (CRC) screening. Patients' ages were 40 to 74 years (mean 53.9, SD 8.7) including 40.8 % African Americans, 4.2 % Latinos, 23.2 % with Medicaid and 10.9 % without any form of insurance. INTERVENTION: The 6-month intervention to promote cancer screening included letters, automated phone calls, prompts and a mailed Fecal Immunochemical Testing (FIT) Kit. MAIN MEASURES: Rates of cancer screening at 1 year. KEY RESULTS: Three hundred sixty-six patients overdue for screening were randomly assigned to intervention (n = 185) or usual care (n = 181). Primary analysis revealed significantly higher rates of cancer screening in intervention subjects: 29.7 % vs. 16.7 % for mammography (p = 0.034) and 37.7 % vs. 16.7 % for CRC screening (p = 0.0002). In the intervention group, 20 % of mammography screenings and 9.3 % of CRC screenings occurred at the early assessment, while the remainder occurred after repeated interventions. Within the CRC intervention group 44 % of screened patients used the mailed FIT kit. On multivariable analysis the CRC screening rates remained significantly higher in the intervention group, while the breast cancer screening rates were not statistically different. CONCLUSIONS: A multimodal intervention significantly increased CRC screening rates among patients in a safety-net primary care practice. These results suggest that relatively inexpensive letters and automated calls can be combined for a larger effect. Results also suggest that mailed screening kits may be a promising way to increase average-risk CRC screening.

A multimodal intervention to promote mammography and colorectal cancer screening in a safety-net practice.

BACKGROUND: There are limited data regarding interventions designed to improve cancer screening rates in safety-net practices with "real world" patients. OBJECTIVE: To examine the impact of a multimodal intervention on mammography and colorectal cancer (CRC) screening rates in a safety-net practice caring for underserved patients. METHODS: At an inner-city family medicine practice, all patients past due for mammography or CRC screening were assigned to receive or not receive a screening promotion intervention based on their medical record number. The 12-month intervention included outreach to patients (tailored letters, automated and personal phone calls) and point-of-care patient and clinician prompts. The trial was registered at clinicaltrials.gov, NCT00818857. RESULTS: We enrolled 469 participants aged 40 to 74 years, including 28% African Americans, 5% Latinos, 25% with Medicaid, and 10% without any form of insurance. Participants in the intervention group showed statistically significantly higher rates of cancer screening; rates were 41% vs 16.8% for mammography and 28.8% vs 10% for CRC screening. These findings were confirmed in multivariable analysis. Similar relative improvements in screening were seen across race, ethnicity, socioeconomic status, and insurance groups. DISCUSSION: A multimodal intervention shows promise for improving rates of mammography and colorectal cancer screening within a safety-net practice. Further study will identify the most cost-effective components of the intervention.

Reducing Barriers and Achieving Success in Registration Examination Among Internationally Educated Nurses: A Participatory Action Research Project.

BACKGROUND: Multiple challenges impede the Internationally Educated Nurses (IENs) professional development and success in writing the registration examination. This paper aims to explore these challenges and describes the educational program which adopts a tailored mentoring approach to facilitate their successful completion of the registration exam.Methodology: Participatory Action Research model informed the development and revision of the educational process. For this qualitative study, individual 1:1 audiotaped and telephone interviews were conducted among the initial participants to explore their experiences in the program. RESULTS: Findings from this study provided more insights as to participants' success in passing registration examination and enhanced performance in their clinical practices. From the thematic analysis, we interpreted the IEN's journey in their knowledge transition into four major themes: Acknowledging the barriers, Learning the new culture, Making progress, Transitioning into power. CONCLUSION: This project demonstrated that the integration of a strong mentor-mentee relationship that gives voice to the participants' learning experience so as to meet their knowledge gaps, engenders a deeper understanding of Canadian professional nursing practice, positions them for success in writing the registration examination and builds a sense of empowerment among them.

Reoperative cardiac surgery in Jehovah's witness patients with patent internal thoracic artery grafts: how far can we push the envelope?

Reoperative cardiac surgery in Jehovah's Witness (JW) patients with patent internal mammary arteries is a formidable surgical challenge. We have successfully performed 2 such cases using creative approaches. The first patient, a morbidly obese woman, presented with an acute coronary syndrome 4 years after off-pump coronary artery bypass grafting (CABG) with a hemoglobin of 10 gm/dL. She was stabilized with stenting of the culprit vessel; erythropoietin therapy was performed to increase her hemoglobin, and surgery was performed electively. The internal thoracic artery (ITA) was dissected and clamped, and intermittent cardioplegia was used for myocardial protection. The second patient needed aortic valve replacement 3 years after a previous CABG using an ITA. Limited dissection was used at redo operation without exposing the ITA. Aortic valve replacement was performed under cold fibrillatory arrest with an open ITA. Successful reoperative cardiac surgery in JW patients requires preoperative preparation using a multidisciplinary team approach and flexible operative planning.

Recurrent Venous Thromboembolism in Two Patients With Cancer Taking Rivaroxaban.

Pharmacologic agents for the treatment and prevention of venous thromboembolism in the cancer patient population are limited. Currently, low-molecular-weight heparin is recommended by national consensus guidelines for this indication. Rivaroxaban, an oral factor Xa inhibitor, is Food and Drug Administration (FDA) approved for the treatment and prevention of venous thromboembolism and offers the convenience of oral fixed-dose regimens, no routine laboratory monitoring, and has few drug and dietary interactions; however, its use in patients with cancer has not been largely studied. We report 2 cases of recurrent venous thromboembolism in patients with active cancer on rivaroxaban therapy. The first case is a 64-year-old female admitted for recurrent pulmonary embolism, and the second case is a 70-year-old female admitted for recurrent deep vein thrombosis. Both patients were receiving rivaroxaban at the time of thromboembolic recurrence. These cases serve as a reminder to health-care providers that more safety and efficacy data in the cancer patient population are needed prior to using rivaroxaban for venous thromboembolism treatment.

"Bloodless" Neurosurgery Among Jehovah's Witnesses: A Comparison with Matched Concurrent Controls.

BACKGROUND: Jehovah's Witnesses (JW) are a Christian faith with >1 million members in the United States who do not accept autologous blood transfusions. The optimal management of these patients undergoing neurosurgical procedures is not well defined. Here, we examined the feasibility and safety of JW undergoing neurosurgery in a blood management program. STUDY DESIGN AND METHODS: Sixty-eight JW patients including 23 men and 45 women (mean age 53 ± 12 years) who underwent a variety of cranial (n = 19) and spinal (n = 49) neurosurgical procedures during a 5-year period were identified retrospectively and their hospital charts, anesthetic records, and operative reports reviewed. A concurrent cohort of sex-, age-, and procedure-matched non-JW controls also was identified. RESULTS: Among JW patients, a cell-saving system was used in 27 cases, with blood retransfused in 13 cases. Lactated Ringers solution was used extensively intraoperatively; albumin was given to 15 patients. The median decrease in hemoglobin was 2.1 g/dL. One patient had a postoperative hemoglobin value <7 g/dL. One patient returned to the operating room to revise a lumbar pedicle screw, and one patient had postoperative seizures. No cardiopulmonary complications, sepsis, pneumonia, or wound infection were observed. Compared with the matched control group, similar outcome results were observed. Blood loss and operative time also were similar in JW patients and controls. CONCLUSIONS: Neurosurgical procedures in Jehovah's Witnesses are feasible, safe, and have similar outcomes to patients willing to accept transfusion when managed within a multidisciplinary blood-management program.

Trans fatty acid intake is related to emotional affect in the Adventist Health Study-2.

Trans fatty acids in Western diets increase health risks, and have been associated with the risk of depression. We hypothesized that intakes of trans fatty acids (primarily from margarines and baked goods) were inversely associated with positive affect and positively associated with negative affect in a longitudinal study. Church attendees residing in North America completed a food frequency questionnaire in 2002-6 as part of the Adventist Health Study-2. A subset in which we excluded participants with established cardiovascular disease (n=8,771) completed the Positive and Negative Affect Schedule (PANAS) in 2006-7. The associations between dietary intakes of fatty acids to positive and negative affect were tested with linear regression analysis controlling for age, gender, ethnicity, education, body mass index, exercise, sleep, sleep squared, Mediterranean diet, total energy intake and alcohol. Intakes of trans fatty acids were inversely associated with positive affect (ß=-0.06, B=-0.27 [95% CI -0.37, -0.17], p<.001) and positively associated with negative affect (ß=0.05, B=0.21 [95% CI 0.11, 0.31], p<.001). In comparison, we found no association between n-3 polyunsatured fatty acids (PUFA) intakes with affect. The n-6:n-3 PUFA ratio was inversely associated with positive affect (ß=-0.03, B=-0.34 [95% CI -0.58, -0.10], p=0.006). The findings suggest that a lower dietary trans fatty acid intake has beneficial effects on emotional affect while the n-6: n-3 ratio is detrimental to positive affect.

Autologous stem-cell transplantation can be performed safely without the use of blood-product support.

PURPOSE: Autologous stem-cell transplantation has been shown to be a curative procedure for a variety of leukemias and lymphomas. Most transplants require RBC and platelet support. We report the ability to perform autologous transplantation without blood-product support. SUBJECTS AND METHODS: In this study, we treated 26 patients with religious objection to blood products with autologous stem-cell support without the use of any blood products. Patients received a combination of granulocyte colony-stimulating factor (G-CSF), erythropoietin, and interleukin-11 or G-CSF alone to mobilize stem cells. Post-transplant patients received intravenous iron, erythropoietin, G-CSF, and epsilon aminocaproic acid. RESULTS: There were two major bleeding complications (8%), with two treatment-related deaths (8%). There were three minor bleeding complications (12%). The median fall in hemoglobin level was 4.7 g/dL; the median hemoglobin level 30 days after transplantation was 9.2 g/dL. The median total number of days with platelet count less than 10 x 10(9)/L was 4 days; the median days to platelet recovery greater than 20 x 10(9)/L was 12 days. CONCLUSION: Autologous stem-cell transplantation can be performed safely without the use of any blood products.

Autologous Stem-Cell Transplantation Without Hematopoietic Support for the Treatment of Hematologic Malignancies in Jehovah's Witnesses.

PURPOSE: Autologous stem-cell transplantation (ASCT) has shown to provide curative benefit in patients with relapsed lymphoma and multiple myeloma (MM), often requiring hematopoietic support until marrow engraftment. Because of Jehovah's Witnesses' (JW) refusal of blood products, treatment challenges arise. This study represents 125 JWs with lymphoma (n = 55), MM (n = 68), or amyloidosis (n = 2), treated with high-dose chemotherapy (HDC) and ASCT without transfusions. PATIENTS AND METHODS: Priming with intravenous iron and erythropoietin occurred to increase hemoglobin (Hb) pretransplantation. Cytokine mobilization of stem-cells was used. Delay to HDC was done to allow Hb and platelets to approach 11 g/dL and 100 × 10(3)/µL, respectively. Patients with MM received a standard dose of melphalan 200 mg/m(2), with dose reduction for severe kidney dysfunction. Patients with lymphoma received carmustine 300 mg/m(2), cyclophosphamide 1,500 mg/m(2) on days 2 through 5 (total 6 g/m(2)), and etoposide 700 mg/m(2) per day on days 2 through 4 (total 2,100 mg/m(2)). Post-transplantation, a combination of granulocyte colony-stimulating factor, erythropoietin, aminocaproic acid, and phytonadione was administered. RESULTS: There were two major and 15 minor bleeding complications, none occurring at platelets less than 5.0 × 10(3)/µL, with six (4.8%) treatment-related mortalities. The median decrease in Hb was 5.0 g/dL, with median Hb nadir of 7.0 g/dL. The median number of days with platelet count less than 10 × 10(3)/µL was 3, with median platelet nadir of 5.0 × 10(3)/µL. Cardiac complications occurred in 40 patients (32%). CONCLUSION: ASCT can safely be performed without transfusion support. A platelet transfusion trigger of ≤ 5 × 10(3)/µL may be appropriate in select patients. Pharmacotherapy and cardiac monitoring are effective in the management of cardiac complications.

Effects of Buspirone on Agitation Associated With Dementia.

Ten patients with probable Alzheimer's disease participated in an open-label study of buspirone for agitation. The starting dose of 15 mg/day was increased by 5 mg every week until maximal improvement or 60 mg/day was reached. A significant decrease in agitation scores occurred at an average dose of 35 mg/day.

The development of an assessment and intervention falls guide for older hospitalized adults with cardiac conditions.

BACKGROUND: Older patients with chronic cardiac conditions are more vulnerable to falls and injuries. Cardiovascular conditions, prevalent in older people, are also the frequent cause of potentially harmful fall injuries among this group. The need to identify the fall risk-related factors that cluster with arrhythmia and syncope is relevant as it will potentially reduce patients' risk for falls and fall injuries. AIM: The paper describes the process taken to design, develop and implement a practice-change initiative that specifically focuses on cardiac-related falls and injuries. PROCESS: A review of best practice guidelines, related studies and patients' profiles from chart audits were utilized to obtain evidence-based information to develop this assessment and intervention falls guide. Prior to the development of this guide, the charts of six patients were reviewed to assess specific data including age, history of falls, type of injury, cognitive function and underlying medical conditions. The developed Assessment and intervention falls guide was utilized with seven patients in the Cardiology Unit who were admitted with diagnosis of syncope and atrial fibrillation to assess their risk for falls. CONCLUSION: The project demonstrated an evidence-informed process that was used to design and implement this assessment tool and a change in nursing practice. It also provided information about the prevalence of cardiac-related risk fall factors that were utilized in the development of this Assessment and Intervention Falls Guide for elderly people.

Intake of Mediterranean foods associated with positive affect and low negative affect.

OBJECTIVE: To examine associations between consumption of foods typical of Mediterranean versus Western diets with positive and negative affect. Nutrients influence mental states yet few studies have examined whether foods protective or deleterious for cardiovascular disease affect mood. METHODS: Participants were 9255 Adventist church attendees in North America who completed a validated food frequency questionnaire in 2002-6. Scores for affect were obtained from the positive and negative affect schedule questionnaire in 2006-7. Multiple linear regression models controlled for age, gender, ethnicity, BMI, education, sleep, sleep squared (to account for high or low amounts), exercise, total caloric intake, alcohol and time between the questionnaires. RESULTS: Intake of vegetables (ß=0.124 [95% CI 0.101, 0.147]), fruit (ß=0.066 [95% CI 0.046, 0.085]), olive oil (ß=0.070 [95% CI 0.029, 0.111]), nuts (ß=0.054 [95% CI 0.026, 0.082]), and legumes (ß=0.055 [95% CI 0.032, 0.077]) were associated with positive affect while sweets/desserts (ß=-0.066 [95% CI -0.086, -0.046]), soda (ß=-0.025 [95% CI -0.037, -0.013]) and fast food frequency (ß=-0.046 [95% CI -0.062, -0.030]) were inversely associated with positive affect. Intake of sweets/desserts (ß=0.058 [95% CI 0.037, 0.078]) and fast food frequency (ß=0.052 [95% CI 0.036, 0.068]) were associated with negative affect while intake of vegetables (ß=-0.076 [95% CI -0.099, -0.052]), fruit (ß=-0.033 [95% CI -0.053, -0.014]) and nuts (ß=-0.088 [95% CI -0.116, -0.060]) were inversely associated with negative affect. Gender interacted with red meat intake (P<.001) and fast food frequency (P<.001) such that these foods were associated with negative affect in females only. CONCLUSIONS: Foods typical of Mediterranean diets were associated with positive affect as well as lower negative affect while Western foods were associated with low positive affect in general and negative affect in women.

Cardiac surgery in Jehovah's Witness patients: ten-year experience.

BACKGROUND: Cardiac surgery in Jehovah's Witnesses poses unique challenges. We have developed a comprehensive multimodality program for these patients and have obtained excellent results. METHODS: Ninety-one Jehovah's Witness patients underwent cardiac surgery between 2000 and 2010. Preoperative, intraoperative, and postoperative considerations in the conduct of bloodless surgery in the Jehovah's Witness population are discussed. Mortality for isolated coronary artery bypass graft surgery and isolated aortic valve replacement was compared with predicted mortality from The Society of Thoracic Surgeons (STS) risk models. Perioperative outcomes were stratified by urgent and elective status of operations. RESULTS: Mean age was 65±12.4 years. Comorbid conditions included hypertension (84.6%), diabetes mellitus (48.4%), previous myocardial infarction (23.1%), chronic lung disease (38.5%), peripheral vascular disease (20.9%), and renal failure (11%). In-hospital mortality was 5.5% (n=5). Mortality for isolated coronary artery bypass graft surgery and isolated aortic valve replacement was 2.2% (observed to expected ratio=1.05, 95% confidence interval: 0 to 3.02) and 5.6% (observed to expected=1.46, 95% confidence interval: 0 to 3.76), respectively. Other complications included reoperation (all=8.8%, cardiac=2.2%), sepsis (2.2%), sternal wound infection (1.1%), transient ischemic attack (1.1%), renal failure requiring dialysis (1.1%), and prolonged ventilation (18.7%). Major complication rates were not significantly different between the elective group and the urgent group. CONCLUSIONS: Bloodless cardiac surgery in Jehovah's Witness patients can be performed with excellent outcomes in both elective and urgent situations. Mortality rates for isolated coronary artery bypass graft surgery and isolated aortic valve replacement are within the expected 95% confidence intervals of STS predicted mortality.

Iron deficiency anemia in women across the life span.

Anemia is a global health issue with disproportionately high prevalence in women. In addition to being an independent risk factor for decreased quality of life and increased morbidity and mortality, anemia in women has been linked to unfavorable outcomes of pregnancy and other issues for children born to anemic women. Iron deficiency is the leading cause of anemia in many populations. Guidelines recommend proactive screening for anemia, particularly in the preoperative setting. Once anemia is diagnosed, treatment should be based on etiology (most commonly, iron deficiency followed, in order of prevalence, by inflammation or chronic disease). Iron supplementation (oral and intravenous) offers safe and effective treatment for anemia associated with iron deficiency. Anemia of chronic disease may be more challenging to treat, and attention must be given to the underlying disease, along with use of hematinic agents. Given its enormous impact on the health and well-being of women and the availability of simple and effective treatment options, anemia should never be left unmanaged.

A journey to patient-centered care in Ontario, Canada: implementation of a best-practice guideline.

PURPOSE: This article describes the process undertaken to implement the Best-Practice Guideline on Client (patient)-centered care. Curriculum development, the application of theoretical frameworks, and the use of a variety of models for care and learning are described. Clinical nurse specialists demonstrated successful curriculum development, facilitation, and research uptake by participants. BACKGROUND: As a Canadian teaching hospital, we are committed to promoting a variety of evidence-based practice guidelines that are systematically developed and framed around a core set of values consistent with our ethical frameworks and based on current research and theories. Many guidelines are prescriptive; however, this particular guideline posed challenges because of its conceptual and philosophical nature. DESCRIPTION: Challenges of curriculum development were resolved using the "know-do-be" framework and "proximity" as the element of the caring component of patient-centered care. Elements of narrative theory and inclusion of nursing and other experiential learning models were utilized. Competing corporate initiatives that linked with client-centered care were included. OUTCOMES: The process resulted in the development of a 12-week course entitled "The Telling Stories of our Practice-Client-Centered Care." Evidence of sustainability and spread of this best-practice guideline to other corporate initiatives through research, patient safety workshops, nursing staff orientation, and other educational activities focusing on professionalism, quality of work life, and falls prevention is described. CONCLUSIONS: Clinical nurses specialists and other advanced practice nurses demonstrated clinical competencies in initiating changes that resulted in increased use of evidence-based practice.